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    <td width="416" valign="top" style="padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0in; padding-bottom: 0in"><p class="MsoNormal" align="center" style="text-align:center;text-indent:0in">
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      <span style="font-size:10.0pt;
  font-family:&quot;Times New Roman&quot;">U&#7926; BAN NH&Acirc;N D&Acirc;N T&#7880;NH<br />
        TH&Agrave;NH PH&#7888;
        <o:p> </o:p>
      </span></p>
        <p class="MsoNormal" align="center" style="text-align:center;text-indent:0in"><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;">S&#7889;:#LICENSE_NUMBER#/UB-Q&#272;
              <o:p> </o:p>
      </span></p></td>
    <td width="526" valign="top" style="padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0in; padding-bottom: 0in"><p class="MsoNormal" align="center" style="text-align:center;text-indent:0in"><span style="font-size:10.0pt;font-family:&quot;Times New Roman&quot;">C&#7896;NG
      HO&Agrave; X&Atilde; H&#7896;I CH&#7910; NGH&#296;A VI&#7878;T NAM
      <o:p> </o:p>
    </span></p>
        <p class="MsoNormal" align="center" style="text-align:center;text-indent:0in"><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;">&#272;&#7897;c
          l&#7853;p - T&#7921; do - H&#7841;nh ph&uacute;c
          <o:p> </o:p>
        </span></p>
      <p class="MsoNormal" align="center" style="text-align:center;text-indent:0in"><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;">&nbsp;
            <o:p> </o:p>
        </span></p>
      <p class="MsoNormal" align="center" style="text-align:center;text-indent:0in"><i><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;">TP.Vũng Tàu,
      </span></i><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;">#LICENSE_DATE#</span></p>
      <p class="MsoNormal" align="center" style="text-align:center;text-indent:0in"><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;">S&#7889;
        h&#7891; s&#417;:#LICENSE_NUMBER#</o:p>
      </span></p></td>
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<p class="MsoNormal"><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;">&nbsp;
      <o:p> </o:p></span></p>
<p class="MsoNormal" align="center" style="text-align:center;text-indent:0in;
page-break-after:avoid"><b><span style="font-size: 10.0pt; font-family: Times New Roman; letter-spacing: 1.4pt">GI&#7844;Y
XÁC NH&#7852;N NG&#431;&#7900;I HO&#7840;T &#272;&#7896;NG KHÁNG CHI&#7870;N</span><span style="font-size:10.0pt;font-family:&quot;Times New Roman&quot;;
letter-spacing:1.2pt">B&#7882; NHI&#7876;M CH&#7844;T &#272;&#7896;C HÓA H&#7884;C<br />
</span></b><span style="font-size:10.0pt;font-family:&quot;Times New Roman&quot;;
letter-spacing:1.2pt"> </o:p>
</span></p>
<p class="MsoNormal"><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;">&nbsp;
      <o:p> </o:p>
</span></p>
<p class="MsoNormal" align="center" style="margin-top:.25in;margin-right:0in;
margin-bottom:8.0pt;margin-left:0in;text-align:center;text-indent:0in;
page-break-after:avoid"><b><span style="font-size:16.0pt;font-family:&quot;Times New Roman&quot;;
letter-spacing:1.2pt"></o:p>
</span></b></p>
<p class="MsoNormal" style="text-indent:.5in;page-break-after:avoid"></p>
<p class="MsoNormal" style="text-indent:.5in;page-break-after:avoid"><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;"><font size="4">Ông,
bà: #NAME#</font></span></p>
<p class="MsoNormal" style="text-indent:.5in;page-break-after:avoid"><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;"><font size="4">Sinh
  ng&agrave;y #NGAY_SINH#</font></span></p>
<p class="MsoNormal" style="text-indent:.5in;page-break-after:avoid"><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;"><font size="4">Nguyên
qu&aacute;n: #NGUYEN_QUAN#</font></span></p>
<p class="MsoNormal" style="text-indent:.5in;page-break-after:avoid"><font size="4">Trú quán<span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;">:
#TRU_QUAN#</span></font></p>
<p class="MsoNormal" style="text-indent:.5in;page-break-after:avoid"><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;"><font size="4">Nh&#7853;p
ng&#361; tham gia kháng chi&#7871;n ngày#NGAY#....</font>
</span></p>
<p class="MsoNormal" style="text-indent:.5in;page-break-after:avoid"><span style="mso-bidi-font-size: 12.0pt; font-family: Times New Roman"><font size="4">C&#417;
quan &#273;&#417;n v&#7883;:#COQUAN#</font></span></p>
<p class="MsoNormal" style="text-indent:.5in;page-break-after:avoid"><span style="mso-bidi-font-size: 12.0pt; font-family: Times New Roman"><font size="4">B&#7883;
nhi&#7877;m ch&#7845;t &#273;&#7897;c do th&#7901;i gian &#7903; chi&#7871;n tr&#432;&#7901;ng t&#7915; ngày:#TUNGAY#...
t&#7899;i ngày#DENNGAY#</font></span></p>
<p class="MsoNormal" style="text-indent:.5in;page-break-after:avoid"><span style="mso-bidi-font-size: 12.0pt; font-family: Times New Roman"><font size="4">Tình
tr&#7841;ng b&#7843;n thân:.#TINHTRANG#....</font></span></p>
<p class="MsoNormal" style="text-indent:.5in;page-break-after:avoid"><span style="mso-bidi-font-size: 12.0pt; font-family: Times New Roman"><font size="4">B&#7879;nh
t&#7853;t hi&#7879;n nay:..#BENHTAT#..</font></span></p>
<p class="MsoNormal" style="text-indent:.5in;page-break-after:avoid"><span style="mso-bidi-font-size: 12.0pt; font-family: Times New Roman"><font size="4">Có
con b&#7883; d&#7883; d&#7841;ng d&#7883; t&#7853;t:#CON#</font></span></p>
<p class="MsoNormal"><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;">&nbsp;
      <o:p> </o:p>
</span></p>
<p class="MsoNormal" style="text-indent:.5in;page-break-after:avoid"><span style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;"> </o:p>
</span></p>
<p class="MsoNormal" style="text-indent:219.75pt"><span style="font-size: 10.0pt; font-family: Times New Roman">TM.</span><span style="font-size:10.0pt;
font-family:&quot;Times New Roman&quot;"> UBND&nbsp; <o:p> &nbsp;
</span></p>
<p class="MsoNormal" style="text-indent:219.75pt"><span style="font-size: 10.0pt; font-family: Times New Roman">CH&#7910;
T&#7882;CH</span></p>
<p class="MsoNormal" style="text-indent:219.75pt"><span style="mso-bidi-font-size:
12.0pt;font-family:&quot;Times New Roman&quot;">(K&yacute; t&ecirc;n, &#273;&oacute;ng d&#7845;u) </span></p>
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